Cropous Pneumonia.


Synonyms:—Pneumonitis; lobar pneumonia; fibrinous pneumonia; lung fever.

Definition:—An acute disease, characterized by a specific inflammation of the lung tissues, accompanied by an exudate of coagulable lymph on fibrin, which results in consolidation of the intimate structure of a lobe or lobes, rendering the air cells impervious to air.

Correctly considered the term pneumonia comprehends a condition of the parenchyma of the lung, in which, with initial hyperemia and acute or sub-acute inflammation, there is consolidation of a portion of this structure.

An occasional writer of prominence describes the primary pathological condition of this disease as if the hyperemia or congestion was the result of a previously existing inflammation, as if the initial condition was inflammation. To us acute inflammatory action has for its basis hyperemia, from which it develops, and if hyperemia, congestion or initial engorgement can be prevented in toto there can be no inflammation. This preliminary hyperemia is induced by the local irritating influence of that which is recognized as the cause of the disease, whether it be a specific micro-organism, exposure to cold or any of the many other possible causes.

In the processes of the development of this disease, which is usually confined to one lobe (although it may involve the entire lung, or as in so-called double pneumonia, involve both lungs), there are three distinct stages recognized. The first stage—the initial or preliminary stage, without which there can be no actual acute inflammation— is the stage of engorgement. In this stage the capillaries throughout the intervesicular structure, from the irritation referred to, become dilated and loaded with blood. Quickly following, in the natural course, the air cells and bronchioles are filled by exudation, with a fibrinous material, mixed with both white and red blood corpuscles and serum, from which that portion of the lung becomes less resilient and impervious to the passage of air. The lung is increased in bulk, swollen or distended, becomes heavier and firm to the touch and docs not collapse upon opening the chest.

After perhaps forty-eight hours, as the disease progresses, the stage of red hepatization occurs. The swollen condition of the diseased portion of the lung becomes greatly increased, the tissues become solid and firm, the lumen of the alveoli is abolished and the structure of the tissue is dark red, mottled and friable, devoid of crepitation as the air is excluded, and an excised piece will sink in water. Its surface will show the impress of the ribs. The air cells, air passages and bronchioles are completely plugged with fibrin. This stage of the disease may exist for from five to seven or eight days.

The third stage of the disease is its terminal stage—the stage of resolution or gray hepatization. In this stage the extravasated cells undergo fatty degeneration, the fibrin becomes softened, there is an increased quantity of leucocytes and the red blood corpuscles have disappeared. A cut surface of the lung tissue will show a grayish appearance, is mottled in color, and from it yellowish white fluid will exude. The friability of the lung tissue is increased, absorption and expectoration of the exudative material follows, unloading the air cells, which return to their normal state and gradually resume their function as the lining epithelium is renewed.

In cases that terminate unfavorably there may be an infiltration of pus cells through the interstitial structure, or there may be abscess or gangrene, or in cases that do not prove fatal, but become chronic in character, an actual induration may result from the formation of new tissue in the air vesicles, or in the interstitial tissues, or in both, connected by fibrous bands, which are supplied with blood vessels.

Etiology:—It is the author's opinion that in the treatment of this disease the predisposing causes are of more importance and should receive greater attention than the actual exciting cause, which is undoubtedly the specific micro-organism, the micrococcus latueolatus of Fraenkel, known as the pneumococcus.

The predisposing causes are many. The most common are sudden temperature changes, and cold, which is a most direct and potent factor in the production of the abrupt or acute congestion, and ultimate stasis, upon which the inflammatory action depends. Cold not only induces this preliminary pathological condition, but it renders the structures unduly susceptible to the action of the specific germ. That cold has much to do with the production of the disease is proven by the fact that in November, December, January, February and March a very large percentage of the cases occur, and that very few, if any, cases occur during the steady heat of the summer.

The disease most commonly occurs sporadically, as the individual is alone brought into contact with the causes. Endemic outbreaks occur also, from a number of individuals having been brought in contact with the same cause. In one family, under the author's observation, which consisted of four children, a defective furnace failed entirely during a severe spell of weather. Each member of the family suffered from a severe cold. The children were attacked one after the other with acute pneumonia. The mother took care of them all for several days, the father going away to his work. The father was then attacked, and a nurse was employed, but the mother escaped. A number of individuals in the same tenement house, or in an institution, a hospital ward, or in a prison, may be attacked within a limited time. But while the disease may be very prevalent in any given locality, it is doubtful if it should be said to be ever truly epidemic in character.

This form of pneumonia is more frequent during full adult age, and among males than females, due to the more frequent exposure to the inducing cause, as out-door employment and alcohol. It occurs without regard to sex, in infancy, in childhood and in old age. If the lower classes and the poor are more frequently attacked it is probably from want and lack of proper protection. Alcoholics are Specially liable, and those who suffer from chronic organic disease. Those who have suffered nervous shock, or who have sustained a severe injury of the chest walls, especially direct injury, or who suffer from burns, or those who have inhaled smoke, fumes, gases or hot air, are liable to attacks.

NTot only is there no immunity to the disease, conferred by an attack of pneumonia, but the patient, once attacked, is rendered susceptible to future attacks, a number of which may occur with increasing frequency or at irregular intervals. The susceptibility, however, is decreased as time passes without a recurrence. The disease also follows other acute diseases, notably influenza.

Symptomatology:—The symptoms of acute pneumonia vary greatly in different patients, each presenting the evidences of a typical case. There is a distinct chill, which may be prolonged for from one to three hours, during which the temperature rises rapidly until it reaches from 103° to 105° F. within the first twenty-four hours, and continues, but with remissions, for from five to nine days, when the crisis will occur. With the occurrence of the fever the secretions are suppressed, the face is flushed, especially that cheek on the affected side, which is apt to show a circumscribed bright red spot; the skin becomes dry and hot; the pulse is quickened and the respiration increases in rapidity, as there is an increase in the amount of lung tissue involved. The relation between the pulse rate and the temperature, when the disease is well established, is somewhat characteristic, as the pulse is apt to be much slower than is usually the case with so high a temperature. It is not uncommon to observe a large, round, full, rather hard pulse of only 90 or 95, with a temperature of from 103.5° to 104° F., and respirations from 30 to 36 per minute. Neither is the pulse rate greatly increased as the respiration is increased. The patient becomes rapidly prostrated, is restless, with perhaps slight delirium, with much headache. Pain is present in the affected area, but it varies greatly with different patients; with some it is complained of bitterly, and is acute, lancinating or cutting in character, especially if the pleura be involved. With this there may be an absence of deep soreness, or there may be extreme soreness and tenderness over the affected area, which is increased by movement or percussion. Infants will cry out during percussion and also when lifted by placing the hands around the chest in the axillae. With other patients there may be only extreme soreness, or there may be an absence of both pain and soreness, or pain may be present on inspiration only, and thus cause irregular, jerky and imperfect respiration, from which, in a short time, there will be more or less cyanosis. Occasionally the pain is referred to the abdomen, in the side or loin or to the location of the larger abdominal glands, or to some other distant location. Nervous excitability and irritability are often present, and intractable insomnia is a very common accompaniment.

The interrupted inspiration, a little short jerk or catch in each inspiration is quite characteristic of the disease in infants. It will occur in each of three or iour efforts consecutively at deeper inspiration and is followed by several short and very shallow respirations. In some cases cough is present from slight bronchial irritation and hyperemia, before the attack of pneumonia. If so, it will usually increase in severity most materially during the first twenty-four hours. In other cases it is concurrent with the rise of temperature and increases as the temperature increases. When so occurring it is usually dry and distressing, or exceedingly painful in character. Later there is some little expectoration, which, as it increases, becomes somewhat uniformly stained with blood. This appearance is characteristic of this disease, the sputum being designated as "rusty colored sputum." Later the sputum becomes tough and tenacious in character, is somewhat gelatinous and contains both white and red blood corpuscles, the characteristic bacilli and other micro-organisms.

In the stage of gray hepatization, as the inflammatory symptoms abate and resolution progresses, the cough may increase as the expectoration of the inflammatory products becomes active and is moist in character, usually much less painful, and the expectoration is very free.

Sometimes in the early stage of the disease there is an entire absence of cough for perhaps two or three days. This the author has noticed in a number of cases, especially among children.

Vomiting may occur early, with complete loss of appetite and excessive thirst. The urine is dark colored, scanty, of high specific gravity, although with diminished chlorides. Often uric acid and the urates are perceptible when the urine is cooled, and later albumin is found present. Constipation is quite constant, although instead there may be diarrhea.

There is an occasional case of croupous pneumonia, which, in its initial stage assumes a markedly congestive type. There is the severe chill, with extreme coldness of the extremities and the skin. The temperature at first is low, perhaps subnormal. The congestion, as in one of the author's cases, attacks the entire lung structure, with all the symptoms of pulmonary congestion elsewhere described. This patient, a miner, had been lying in a wet place, on the floor of the mine, in a strong draught, undermining a stratum, lying partly in the water, with his clothes saturated all day.

In these cases the reaction takes place very slowly. Difficult breathing is pronounced from the first, and unless the reaction is induced by active measures will increase and become labored. The face is bloated and of a dusky hue, becoming purplish, the hands are cold and the finger nails are bluish and dark. The temperature will finally rise and quickly reach a high point, perhaps 104° F., with increasing difficulty of breathing, and yet the skin and extremities continue cold. The patient is dull and listless, is not easily aroused and dislikes to talk or does not heed what is said. Cough is usually present, almost from the onset of the congestion. It will vary in character, but is dry and irritating and usually short or barking and quite continuous. The pulse is slow, and when the temperature has reached a high point is not rapid in proportion, seldom exceeding no beats per minute, and is usually from 80 to 95 per minute. The respirations, still labored, however, increase in rapidity with the increase of the temperature, and later the breathing becomes rapid and shallow, with cyanosis. This form of the disease occurs more often in men and in those previously in excellent health—is pronouncedly sthenic in type—perhaps because these expose themselves by their habits and employment to the severe conditions which induce it.

This disease occasionally assumes a distinctly adynamic type when prolonged, and in some cases, where the patient has been previously enfeebled and the blood poor, almost from the first. With the high temperature the pulse is rapid and feeble, the respiration is rapid and shallow, the patient restless and delirium is apt to occur. The mouth becomes dry, the tongue dry and elongated and is soon coated with a dark brown coat; the mucous membranes are red or dark, and there are sordes on the teeth. The symptoms are pronouncedly typhoid in character. In some cases the skin becomes slightly jaundiced, there is tenderness over the liver and the spleen is enlarged. Prostration is extreme and the delirium is soon accompanied with or is followed by stupor.

This form occurs when the disease follows other serious acute disease, or where the patient is greatly enfeebled, and especially in alcoholics, or if, with the onset of the lung inflammation, there is septic infection. It occurs also with those suffering from chronic disease, and especially during the progress of a chronic disease of the kidneys or bladder. Per contra, an acute attack of pneumonia may occur during the progress of a severe case of typhoid fever, when the symptoms will be much as described. In either case it is designated typhoid pneumonia, although the term is more correctly applied when the pneumonia occurs primarily.

Pneumonia in the aged, senile pneumonia, develops without the classic symptoms looked for in middle life. With rather suddenly increased prostration the patient may become seriously ill before evidences of lung involvement are pronounced. When these appear they are somewhat varied in character. The quickened respiration, slightly increased temperature and nervous phenomena do not point strongly to the lung, as there may be an absence of pain, dyspnoea, cough or expectoration. Usually, however, one or more of these symptoms in a mild form are present. Examination of the chest, which may be made only incidentally, will show impaired respiratory movement and dulness on percussion, which is the most conspicuous symptom, and perhaps some sub-crepitant râles, with tubular breathing. The exact condition may be exceedingly difficult of diagnosis, as the symptoms are deceptive and misleading and may terminate fatally before a diagnosis is determined, or suddenly, when the condition was not thought to be at all serious.

Pneumonia often develops during childhood with signs of profound central nervous irritation, with convulsive phenomena and delirium, or stupor, which point strongly to meningeal inflammation and are consequently misleading and deceptive. Or these symptoms may be pronounced, and an actual meningitis may exist conjointly with the characteristic lung phenomena, although this complication is rare. It is more apt to occur after the lung disease has progressed actively some days, or has run its full course.

The author has observed all the respiratory and physical signs of pneumonia in childhood with an absence of cough for the first two or three days. The rusty colored sputum is usually absent also with these patients. Children are more amenable to treatment than adults and recover from the disease more readily and the mortality is lower.

The inhalation of ether has a notable influence in reducing the temperature of all patients. This general reduction of temperature with the irritating influence of the ether in the bronchioles and air cells, in an occasional susceptible patient, tend to induce a typical pulmonary congestion. Reaction follows and fever occurs, with pain in the chest, cough and other characteristic symptoms of acute inflammation.

Alcoholics develop pneumonia readily and in a severe form, with the characteristic lung phenomena. The di-lirium usually becomes extreme and violent, often maniacal and adynamia quickly supervenes. Even with the most careful treatment these cases are usually fatal.

Other complicated forms of croupous pneumonia are malarial or bilious pneumonia, which occurs when there is malarial intoxication, which presents evidences of some hepatic congestion—migratory pneumonia, which is simply the transplantation of the disease to the other lung or to another locality in the same lung, when the whole lung is not involved—and latent pneumonia. This is a questionable form of the disease and may be only a congestion and consolidation of a given area during other diseases, without signs of actual inflammation. The characteristic microbes, however, may be present, and later rusty colored sputum may appear.

Croupous pneumonia usually runs its course within twelve or fourteen days, and occasionally within seven days, or it may be prolonged to three or four weeks. Complications may greatly prolong convalescence and the disease may terminate in abscesses, in gangrene, or in a chronic form of the disease, or tuberculosis may develop from it.

Physical Examination:—In the congestive stage there is deficient motion, with imperfect chest expansion in the diseased side, without evidences of consolidation on percussion. The respiration is largely bronchial, with small crepitant rales in the diseased area, while the normal heart sounds are all exaggerated. This must not mislead the physician in his location of the inflammation. Later, as the disease develops, percussion reveals impairment of resonance, increasing to dulness, if near the surface.

The motion on the diseased side is absent on inspiration, while the side is found to be enlarged when measured. Usually the breathing sounds in the air tubes or bronchi can be heard distinctly, unless the consolidation affects the bronchioles and smaller tubes. Bronchophony is distinct. In the final stage the vesicular breathing returns and there are moist rales.

On palpation there is an increase of the vocal fremitus, at first slight, in the area of hepatization, later more pronounced, with absence of expansion, with perhaps friction fremitus. With the stage of resolution these disappear and the vocal fremitus diminishes.

Differential Diagnosis:—The disease is distinguished by an absence of bronchial symptoms from bronchopneumonia; from pleuritis by the local, .initial, sharp, acute pain on inspiration of the latter disease, with the effusion; from pulmonary edema by the fact that in edema fever and the constitutional symptoms of this disease are absent; from acute tuberculosis by the sweats and diarrhea, which are an early accompaniment, and by the presence of the tubercular bacilli. In the early stage of tubercular invasion a differential diagnosis is often quite difficult.

Pneumonia may be complicated by the occurrence of acute bronchitis, which will increase all the existing phenomena. It is not unusual for a portion of the pleura to become involved early; in fact, it is doubtful if the pleura is not involved to a greater or less extent in most cases, resulting in an actual pleuritis. If this is extensive and is accompanied with effusion, it has in the past received the name of pleuro-pneumonia. It is not, however, a form of pneumonia, but the conjoint existence of the two diseases.

Other possible complications are bronchiectasis emphysema, hydropneumothorax, pericarditis, endocarditis and evidences of other heart involvement, with meningitis and peripheral neuritis or mild paralysis. There may also be present a gastritis or gastro-enteritis, usually catarrhal in character, and, as stated, the liver and spleen may be attacked also in extreme cases, with peritonitis, nephritis or cystitis, of which nephritis is perhaps the most common.

Prognosis:—In uncomplicated cases the prognosis is good. Individuals in previous good health, with good care, should resist acute complications to a large extent. Alcoholics, or those in whom there has been a previous dis-crasia or tuberculosis, will succumb to this disease in perhaps 25 to 30 per cent of the cases. The health reports of large cities show an exceeding high death rate, which seems to have greatly increased within the past ten or fifteen years, it is the author's opinion that in private practice, with patients in fair circumstances, the mortality should not reach five per cent, and with all cases it should not exceed ten per cent.

Treatment:—The severe measures of the past, the antiphlogistic and stimulant course of treatment have resulted invariably in a high mortality. A method of treatment which has produced the most satisfactory results is based upon the fact that the disease is rapidly devitalizing and will admit of no harsh measures, but demands the utmost gentleness and care in its treatment, and great skill in nourishing and sustaining the patient, without unduly stimulating the nervous system or the heart.

There are certain theories and measures yet adopted by the profession at large in the treatment of this disease which have been handed down for many years past, but which are not proven by statistics to have been of great benefit.

The first proposition is that fever is not harmful, but may prove beneficial. This is advocated by a number of writers. No greater fallacy than this was ever enunciated, and only harm can result from its acceptance. One of our writers referring to this statement tersely says, "I would think it as reasonable to tell a man when his house was on fire that the fire was a conservative element, that it was a thorough disinfectant, and would rid his house of vermin, as to tell him, when his wife was suffering from the effects of the high temperature of acute pneumonia, that the fever was a conservative element, a beneficial factor of the disease, that it was favoring tissue metabolism and aiding in the destruction of the specific poison."

The second fallacy is that the theory of the microbic origin of the disease must have first attention in the treatment by the adoption of an antiseptic course, to the exclusion of other measures. It is our experience that antiseptics are not beneficial in this disease until in the course of its advancement, there is apparent breaking down of tissue and threatened sepsis, announced by the appearance of those phenomena which are characterized as typhoid. They should be used also, when evidences of abscess appear in the later stages of the disease, but they must not be depended upon for the amelioration of the total processes.

A third fallacy is that local or general depletion is of permanent benefit. The common sense of the profession at large has long since discarded blood letting, although an occasional writer will yet advocate it. It is not suggested or adopted by the busy, practical, rational, family physician. It is difficult for the profession to rid itself of the idea that an active physic at the onset of the treatment is necessary with which to thoroughly "sweep out" the intestinal canal.

With us a simple laxative, if constipation be present, or a thorough colonic flush is all that is necessary. Disorders of the stomach and pre-existing diarrheas must receive attention, as they will interfere with the nourishing of the patient, will reduce his strength, and encourage the progress of the disease.

Another fallacy is the adoption of persistent stimulation from the onset of the disease. Nothing can be more erroneous than that the heart must be stimulated from the first against possible failure later on. We advocate sustaining the strength of the patient, but to give no heart stimulant whatever until there are evidences of approaching heart weakness. In all the cases that I have observed where strychnin and quinin were given indiscriminately in the early stage of this disease, I have been confident that the temperature has been increased, a high temperature sustained, the nerve tension exaggerated and a condition of general nervous excitability induced.

This results in an aggravation of all the symptoms and antagonizes the action of specific remedies. Delirium often follows also, and we have laid it down as one of our basic principles that as long as delirium is present we are unable to obtain the satisfactory influence of our remedies. These must be directed to the delirium after the cause has been removed.

Still another common fallacy is that the use of cold applications to the chest in antagonizing the advance of this disease, is a rational procedure. The influence of cold upon the capillaries produces congestion, and if persisted in, blood stasis. It induces within the capillaries the exact pathological condition that the causes of any acute inflammation induce. While it primarily produces contraction of the capillaries, secondarily the blood current is slowed and the passage of the corpuscles through the minute capillaries is greatly impeded.

It adds no force or power by which the venous capillaries can empty themselves, while the force of the circulation is continually filling the arterial capillaries. The highly essential metabolism, the throwing off of tissue waste is at once retarded, inhibited, or made impossible by the action of cold. A certain amount of the excess of heat is abstracted, but the fuel is piled up on the smouldering fire, for ultimate greatly increased combustion.

On the other hand, heat applied and persisted in, over the entire diseased area, is a most potent and physiological antagonist to those essential conditions which are directly educed by the causes of the disease, and from which all ultimate pathologic results must develop. It is profoundly stimulating, and while local heat from undue combustion is present, the applied heat stimulates the capillaries and Physiologically unloads the venous capillaries. At the same time it stimulates the arterial capillaries through its influence upon the peripheries of the nerves, and secondly upon the nerve centers, to drive the accumulating tide through the engorged vessels, thus unloading them into the veins. It thus carries off the accumulating waste, brings into the capillaries a new tissue supply and quickly restores the harm that has been done them in the primary congestion. It is a most rational procedure. It is logical, it is reasonable, it is physiological, and it is highly scientific. And such a course is always acceptable. We advise the application of heat at once and that it be persisted in as long as benefit is apparent from the abatement of the symptoms. It cannot possibly do harm.

Finally the opium fallacy must have some attention. The first influence of this remedy in small doses is that of a stimulant, but this influence is so transient that it must not be relied upon. The ultimate result of the influence of opium and morphine upon the capillaries, when given to control the pain of pneumonia, is much the same as that induced by the causes of the disease and by cold. It also paralyzes the nerve endings, as well as induces inactivity of the nerve centers. It slows the capillary circulation, inducing, as is well known, venous stasis, and thus contributes to the local hyperemia. It in no way facilitates normal tissue metabolism, nor the unloading of the morbific matter, but it greatly retards excretion, while it masks or holds in abeyance the evidences of the disease and encourages the advancement of the disease processes. If it is used to subdue the pain, at any time, it should be used in small doses, carefully repeated, and its deleterious influence upon the capillaries should be directly antagonized by heat and belladonna. I have been confident in the past that patients to whom I had been called late, ultimately succumbed to pneumonia because of the use of this remedy. It is especially contra-indicated in conjunction with cold. A careful study of rational specific measures will teach the immediate reduction of pain without opium.

That there is a possibility of the jugulation—the complete abortion—of this disease at its onset is no longer a question of doubt. It has been accomplished sufficiently often, under favorable circumstances, to establish it as a certainty. The cases in which this is possible are the sthenic cases, and those in which there has been no previous disease, and where the case has occurred abruptly with the typical acute development, both in Pathology and symptomatology.

If seen during the onset of the disease, within perhaps twelve hours after the occurrence of the initial chill and fever, the patient should quietly, without effort on his own part or excitement, be given a hot sitz-bath for about twenty minutes, with the chest and body well covered, or he should have a most thorough hot foot bath, into which strong mustard has been stirred. A deep wooden pail or foot bath tub or wide deep jar should be used, so that the legs, nearly or quite to the knees, may be immersed, and retained until from twenty to thirty minutes, until they are very red, but not blistered with the mustard. During this tiine, the patient being thoroughly wrapped in blankets, may at first take from ten to fifteen minims of jaborandi in a teacupful of hot water, or he may drink a hot infusion of asclepias, or in the absence of these, a bowl of hot ginger tea made by adding a dram of the tincture of ginger to half a pint of hot water. The foot bath ended, the patient should be quietly put into a warm bed. The diseased area should be covered with libradol, with antiphlogistine or with the official Kaolin dressing. A rubber water bag containing a half pint of hot water, all air excluded, should be laid over this dressing.

If libradol be used it should be removed at the expiration of six, eight or ten hours, unless the patient should become nauseated early, in which case it should be immediately removed. Either of the other dressings may remain undisturbed for twenty-four hours, with the external heat persistently applied. If perspiration be induced, this may be continued mildly for two or three hours. Other remedies will be indicated and they may be administered as suggested further on. This prompt course or a similar one will occasionally abate the inflammatory processes within forty-eight hours, with no further development, and no results of the disease action except weakness, from which, with the proper tonics, the patient will speedily recover. I have also succeeded in jugulating the disease in abrupt cases with veratrum. The patient should be kept in his room for perhaps a week, with an equable temperature and a moist atmosphere. Great care should be exercised in going out, as the patient will be very susceptible and liable to a return of the disease for an entire season.

In instituting the rational treatment of the disease, when an attempt at its abortion is not expedient, or when such an attempt is unsuccessful, the closest attention should be paid to every evidence of the disease, and the specific indications must be met with precision and exactness. The physician must determine most carefully the exact pathological factors as they develop, recognizing them promptly and meeting them with positiveness and assurance. The treatment must be conducted rationally; the action of the remedies directed in strict physiological lines. Everything must be done with confidence, but without haste, excitement or confusion. The patient must be kept tranquil and quiet, and should be disturbed as little as possible, and talking on his part should be prohibited entirely. Nothing whatever advised should induce pain or nervous irritation, nor should it in the least weaken the patient or lessen even temporarily his vital force.

Two factors in this condition must have our first attention. These are the initial capillary congestion within the pulmonary parenchyma in the diseased area and the temperature. If in the onset the disease is of the congestive type, as will be determined from the symptoms which we have named—the skin cool and respiration somewhat difficult—the indications demand belladonna and prompt external heat, applied over the entire chest. If profound congestion be present the patient should be put into a hot bath or wrapped in a blanket wrung out of water at a temperature of from 85° F. to 95° F., and this covered with dry blankets and retained for perhaps an hour or until the chill has passed. In this type of the disease veratrum exercises a most satisfactory influence, but the indications are those of belladonna, and the two remedies may be given conjointly or alternately. The skin is cool and the extremities cold, the face is dusky or dark in color and has a cold, blue look, the breathing is labored and slowly increasing in rapidity, and the patient is dull and listless, the eyes dull and the pupils somewhat dilated. The pulse is large, full, soft and compressible and probably not above 100 per minute. The temperature is above 102.5° F. and rapidly rising. With these indications veratrum should be given in minim doses every hour, in markedly sthenic cases, until the pulse is reduced to seventy beats per minute. It should be then given in half minim doses until the pulse reaches 60 or 55, unless vomiting occurs, when it should be stopped. It should be then withheld for a few doses in order to determine whether the temperature will continue to decline or will increase. If the reduction is not sufficient it may be given in small doses through the first two days, after which time it is seldom indicated.

It is common practice to give veratrum alone when the indications are typical, as those just named, but ten minims of specific belladonna in four ounces of water, given in dram doses every hour, will intensify its action. This agent is a most positive and direct physiological antagonist to the essential factors involved in the initial congestion and the pathological elements which succeed it in order, in the progress of the development of the disease. It is an active stimulant to the capillary circulation, increasing to a marked degree capillary action, driving the blood out of the venous capillaries and stimulating the activity of the arterioles, thus quickly unloading the congestion. It equalizes the circulation through its uniform influence upon the entire capillary system. It acts in perfect harmony with other special sedatives, although not in itself a sedative to the fever processes.

In the usual development of this disease, while the congestion is developing in the pulmonary structures, there is the initial chill, with temperature rapidly increasing, with flushed face, dry, hot skin and rapid respiration, the pulse is hard, sharp and rather small and usually quite quick, beating perhaps from one hundred to one hundred and ten per minute in adults, and from one hundred and ten to one hundred and forty per minute in children. Belladonna should be given in small doses in this stage, but aconite should be given also for its influence upon the fever. This agent is antagonistic to the congestive processes to a degree, and thus acts in perfect harmony with belladonna. It promotes tone and power in the arterial capillaries, it retards exudation, hepatization, suppuration and adhesion, more certainly antagonizing the inflammatory processes than any other purely sedative remedy; it also hastens resolution and promotes absorption of the inflammatory products. From three to five drops of specific aconite in four ounces of water, given in dram doses every hour, or to children in half-dram doses every half hour, is sufficiently active dosage. With the exception of veratrum in the sthenic cases we do not advise any remedy in sufficiently active dosage to in any way depress the system or reduce the actual power of the heart. The influence of aconite in slowing the heart and reducing the temperature is exercised in a manner much superior to that of actual depression. It inhibits the action of the heat centers, relaxes the sudoriferous glands and yet stimulates them to increased activity, thus promoting the radiation and dissipation of the heat. It antagonizes also the local processes of heat generation in the inflamed area. Its restraining influence on increased heart action is kindly and not depressant. It may be given alone in this disease in small doses frequently repeated, and may be continued as long as the temperature remains high, with the very best of results. No evidences of depression will appear from its use.

Another remedy of prime importance in pneumonia is bryonia. With this remedy alone the author is confident that very many uncomplicated cases will be greatly abridged in course and severity without other medication. The agent is physiologically adapted to the underlying pathological processes. It controls the fever processes and those conditions which are involved in the evolution of the disease. It is continued throughout the course of the disease, whether the patient be feeble or not, if the following indications are present: Pain in the diseased area, which is aggravated by motion, elevated temperature, with a hard, frequent, vibratile pulse, with deficient bronchial secretion. The cough, if present, is dry, short, harsh or hacking, and the local soreness is increased by the coughing. The pain and soreness are relieved by lying on the inflamed side, the face is flushed and the cheek on the affected side has a central, bright red, circumscribed spot. All prescribers who have had experience with this remedy are enthusiastic concerning its influence in antagonizing the inflammation, as it acts similarly to and in some ways superior to aconite. It is specific in its influence upon the pain. Although this influence is not as immediate as opium, it is in line with physiological influence of the agent in abating the processes of the disease. In retarding exudation, hepatization, suppuration and adhesion, and in promoting the removal of the inflammatory products, especially preventing serous effusion. There is an essentially harmonious action between this remedy and aconite. In all acute diseases of the thoracic viscera both should be given, as has been stated, in very small doses, which should be frequently repeated. This statement is reiterated because of its exceeding importance.

Another essential remedy is ipecac. This remedy soothes irritability in the lung structure and in the bronchial tubes with positiveness. It should not be given in sufficient doses to induce even the least nauseating influence. From two to six minims of the specific medicine in four ounces of water, in dram doses every hour or two hours, will allay the pain, sooth an irritating cough, remove distress and assist the other indicated remedies in promoting resolution. It is equally efficient when the bronchial tubes are involved. When resolution has occurred and hepatization remains subsequent to the decline of the fever, this remedy may be administered to adults in much larger dosage. It has been the author's habit after the fever has abated during the earlier stages of convalescence to combine it with the quinin bisulphate—one-fourth of a grain of powdered ipecac to two grains of the quinin salt. When the general nervous force is weakened one-fourth of a grain of the extract of nux vomica may be added to this in a capsule and the whole given every three hours.

The above remedies named comprise the essential ones in the treatment of this disease. There are, however, a number of others whose indications are frequently met with. These we will mention briefly.

Rhus toxicodendron is of service when the pulse is sharp and hard, the temperature high, the tongue red, elongated and pointed, with a pointed tip, the mucous membranes red, and when the pain is relieved by movement and increased by excessive warmth; when the face is flushed a bright red and there is headache or supra orbital pain. The -dose must be very small.

The indications for gelsemium are those of cerebral hyperemia, which is apt to be one of the developing symptoms of the disease in childhood, and which may be accompanied with convulsions. From five to ten drops of the specific medicine, in early childhood, and from ten drops to a dram, in adult age, may be added to four ounces of water and administered in dram doses every half hour or hour while this stage lasts. The symptoms are a brightly flushed face, bright, sharp eyes, contracted pupils, great restlessness and excitability, with a high degree of nerve tension, increased heat in the head and face, hot, dry skin, sharp and quick pulse. It has a pronounced influence upon the heart's action with these symptoms and reduces the temperature. When there is pronounced weakness of the nervous system it must be given in smaller doses and continued only during the active period of the excitement.

Asclepias is indicated when with the inflammation in the lung structure the pleura is involved, as is shown by the characteristic, acute, cutting pain on inspiration. It is also a most excellent sudorific and is indicated when the skin is dry ?nd the secretions are deficient. It works in harmony with aconite. It is also of value when the progress of the disease is slow or when it assumes a chronic form, when it materially assists in removing effusion. It acts more promptly during the course of the fever, over which it exercises a sedative influence.

Sticta pulmonaria is demanded when there is sharp, quick pain under the shoulder blade or when the pain extends to the back of the neck, into the occiput or through the shoulders; when there is soreness or dull pain in the chest or in the extrinsic respiratory muscles, which is increased by deep breathing; when irritative cough is persistent, dry, short, sharp, hacking in character or wheezing or rasping, with quick darting pains in the chest walls. It may be given in conjunction with any one of the other remedies, especially with the sedatives.

Cactus grandiflorus is important in the advanced stages of the disease, when the first evidences of heart weakness appear. Its essentially nutritive influence upon the heart muscle, through a direct tonic effect which it exercises on the central nervous system, makes it an essentially valuable remedy. In asthenic cases it steadies the action of the heart, improves its tone, increases arterial tension and certainly reduces both the pulse rate and the temperature. It may be given in from one to five minim doses every two hours.

Digitalis is not indicated until the evidences of heart failure are actually present, although we have reason to believe that in an indirect manner and inferior to the remedies we have named, in small dosage it will antagonize the development of pneumonia. It whips up the heart, increasing its action and increasing arterial tonus, thus tiding the patient over a crisis until the influence of restorative tonics can be obtained. From two minims to ten minims of the tincture may be given every two to four hours.

We have referred to the action of quinin bisulphate in its tonic influence and as overcoming hepatization and thus restoring the functional action of the air cells. Its action is not limited to this influence alone, it restores the tone and vigor of the entire nervous system and the stomach and intestinal tract. It improves digestion and facilitates the appropriation of nutrition. The remedy is also demanded in malarial pneumonia, to antagonize and destroy the Plasmodium malarife and to overcome periodicity, but it must be remembered that the specific symptomatology of the quinin salts are as exact as those of any other specific remedy. The temperature must be falling and not above 101° F., the skin must be soft, the pulse soft and decreasing in rapidity, the secretions must be restored, the tongue moist and inclined to clean. Under these circumstances only favorable results will occur from the use of this remedy. If in the course of the periodicity this group of symptoms occurs at a given time each day, or on alternate days, with active symptoms at all other times, the agent should be given only during the time these symptoms are present. Capsicum may be given in conjunction with this remedy and will enhance its action.

Hydrastis canadensis is given during convalescence through the entire period. It is a pure active tonic. It materially improves the functional action of every organ. It may be given alone or combined with quinin, iron or nux vomica, or these remedies are sometimes all combined. This, however, is unscientific, although the results may be satisfactory.

Strychnin is useful in the markedly asthenic cases and where heart failure is imminent it should be given only as needed in the form of the sulphate or the nitrate in from one one-sixtieth to one-twentieth grain doses. It is commonly given in conjunction with digitalis, as it exercises upon the nervous system, and through that upon the heart a similar influence. This remedy, if given during the early stage, in a sthenic patient, when there is nervous irritation, with high temperature, will exaggerate all the symptoms of the disease. I am especially favorable to the action of the strychnin arsenate in its tonic and restorative influence.

The ammonium chlorid is administered during the progress of the disease, when expectoration is deficient and when it is desirable to expel the exudative product from the air ceils, which "has induced the consolidation. It is indicated when there is a short, dry, irritative cough and when the cough induces soreness of the chest, especially if present or accompanied with prostration or increasing weakness.

Echinacea is indicated only when the products of microbic invasion or when the result of prolonged high temperature induce evidences of depraved blood and toxaemia. When typhoid phenomena are present this agent is given persistently from their first appearance in ten-minim doses every two hours, in conjunction or alternating with one or more of the remedies which have been named, as shall he indicated. In addition to a profoundly alterative influence its superior tonic and restorative effect will enable it to exercise a satisfactory sedative influence upon the fever and upon the inflammatory processes. Its influence roust be known to be fully appreciated.

The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.